G-19F (proposed) Earnings Information Request

Form Approved
OMB NO.3220-01 84

In reply refer to

The Railroad Retirement Board (RRB) requires earnings information to determine the amount of
benefits you are entitled to for certain years.

*

Please furnish earnings information for the years indicated on the next page by completing items 1,
2 and 3. Also complete items 4, 5 and 6 if an " X appears in the box next to the item. Be sure to
sign and date the form, and provide youhtele hone number.
If you were employed by someone el
report your total wages before payroll deductions
(even if some of your wages were not coveredrr,Q Social Security). Furnish copies of your
Forms W-2 for the years indicated.
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If you were self-employed, use your income tax returns or business records to get the
amount of your self-employment earnings. Furnish copies of Schedule SE, Form 1040, for
the years indicated.
If you or your family have incorporated a business, report your earnings as wages, not self
employment.
If you have
ons about this letter, or if you need additional information, please contact this
~ein person,&!me bring this letter and your earnings information
office. If yo
with you. Our office is open to the public during normal business hours. If you W H F S ~please
,
4
furnish your daytime telephone number.

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Sincerely,

Enclosure: Envelope
SEE NEXT PAGE

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Fonn Approved
OMB No. 3220-0184

EARNINGS INFORMATION REQUEST
(EMPLOYMENT FOR HIRE OR SELF-EMPLOYMENT)
PapemMt ReduUio4$l
Privacy Act Noti
The Rallroad Retlrement Board is autho"zed to collect the following requestginformation under
7(b) 6 of the Railroad Retirement Act (RRA). This
informatlon is needed to deternine if your earnings affect pa ent of your railroad retirement benems. Vou =re not. require! to rovide us with the
Infor~atlonrequested by this form. However, we may not be a% to pay you benefits if you fail to provide us wrth this ~nformabon.R e information you
provlde may be disclosed for purposes of verification to the employers you name In this report.
We estimate this form takes an average of 8 minutes !o complete, including the time for reviewing the instructions, getting the needed data, and reviewing
the completec! form. Federal a encles,may not conduct or sponsor, and respondents are not requrred to respond to, a collection of informabon unless rt
displa s a val~dOMB number. ?f you wrsh send comments regard~ngthe accura of our esbmate or an other aspec f this form, including suggesbons
~ Rush
~ r St.,%icago,
n ~ ~ t1 1 80611-2092.
for reJucing the mmpletion time, to the ~ h koff ~ ~ f o r m a t i o ~ ~ ? ~B ~O t~ ~i .N.

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1. Did you work for yourself or anyone else in any of the years:
YES-Gotoltem2
NO-Got

?

*

?

2. Enter
A name and address
@
!reyo@
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gs from employment for hire or your total net earnings from self-employment for

3.

5.

Calendar Year

Total Annual Eamings $

Calendar Year

Total Annual Earnings $

q

Do you

to work for yourself or anyone else in

If "Yes,
6.

Have y

IJYES

?

IJNO

estimate of earnings.
o

F working?

UYES

NO

If "Yes," bWrrigh date of last employment.
SIGN AND DATE AT BOTTOM
7. REMARKS:

Sign here:
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Telephone Number: (
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